research article radiographic assessment of the technical...

Hindawi Publishing CorporationThe Scientific World JournalVolume 2013, Article ID 514841, 7 pageshttp://dx.doi.org/10.1155/2013/514841

Research ArticleRadiographic Assessment of the Technical Quality andPeriapical Health of Root-Filled Teeth Performed by GeneralPractitioners in a Turkish Subpopulation

E. Tarim Ertas,1 H. Ertas,2 Y. Sisman,3 B. Sagsen,4 and O. Er4

1 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Izmir Katip Celebi University, Izmir 35640, Turkey2Department of Endodontics, Faculty of Dentistry, Izmir Katip Celebi University, Izmir, Turkey3 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Erciyes University, Kayseri, Turkey4Department of Endodontics, Faculty of Dentistry, Erciyes University, Kayseri, Turkey

Correspondence should be addressed to E. Tarim Ertas; [email protected]

Received 2 December 2012; Accepted 9 January 2013

Academic Editors: E. J. Honkala, C. H. Pameijer, and D. Tziafas

Copyright © 2013 E. Tarim Ertas et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Aim. The aim of this study was to evaluate by means of radiographs the technical quality of root fillings performed by dentalpractitioners. Methods and Material. Standardized periapical radiographs were made on 484 patients who received endodontictreatment in private practice. A total of 831 endodontically treated teeth with 1448 roots were evaluated for technical quality of theroot canal filling and the periapical status of the teeth. Also, the apical status of each root-filled tooth was assessed according to thelength, density, and taper of root fillings, and the presence of apical transportation, broken root instruments, and overfilled sealeror gutta-percha material was recorded for each root canal. Results. Of the endodontically treated teeth 26.6% had healthy periapicaltissues, while technically good endodontic treatment constituted 12.8%. Based on the treatment success, there was no significantdifference between the tooth groups. Statistical analysis of the data did not demonstrate statistically significant differences betweenthe various parameters that were evaluated (𝑃 < 0.05). Conclusions. Technical quality of root fillings in a population who receivedtreatment in private practice was poor andwas consistent with a low prevalence of apical health.The probable reasons for this failureare multifactorial and may be improved if the operators improve their skills with continuing postgraduate education programs.

1. Introduction

In many countries, dental health is a rising and importantpublic health problem because of its medical, economic,and ethical repercussions [1], in which root canal treatment(RCT) plays an essential role when considering the qualityof dental care [2, 3]. With the improvement of modernprinciples in endodontic practice, many clinical studies haveshown an increase in the favorable treatment outcomes [4–6]. Epidemiological studies evaluating the outcome of theendodontic treatment performed in controlled clinical envi-ronments (e.g., dental schools) have demonstrated successrates up to 95% [4, 7, 8]. Concerning the recommendationsof competent scientific committees, experts, and professionalguidelines related to the quality of treatments, there isevidence that the quality of treatments completed in general

dental practice is less than ideal [9–11]. Irrespective of thepopulation group and geographic location, success ratesdecrease as low as 35% to 60% [11–15]. As a result, with adecrease in the quality of treatment, there is an increase inthe prevalence of apical periodontitis, so it is necessary toimprove the quality of root canal treatment in general dentalpractice in order to promote periradicular health [16].

There is a general assumption that an endodontist pro-vides treatment of better quality and treatment outcomescompared to generalists, so the aim of this study was to assessthe radiographic assessment of the technical quality andperiapical health of root-filled teeth performed by generalpractitioners in a Turkish subpopulation.

In addition, the quality and type of coronal restorationsand relation between the coronal restoration and periapicalhealth were also evaluated.

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Table 1: Parameters recorded on endodontically treated teeth.

Parameters Criteria DefinitionQuality of root canal treatments

Length of root canal fillingAdequate Root filling ending ≤2mm from the radiographic apex

PoorRoot filling beyond the radiographic apex or root filling >2mm from theradiographic apex

Density of root canal filling Adequate No voids present in the root filling or between root filling and root canal wallsPoor Voids present in the root filling or between root filling and root canal walls

Taper of root canal filling Adequate Consistent taper from the apex to the coronal partPoor Not consistent taper from the apex to the coronal part

Periapical statusHealthy periodontal

ligament If the periodontal ligament was intact with no signs of periapical pathosis

Apical periodontitisIf the widening of the apical part of the periodontal ligament was notexceeding two times the width of the lateral periodontal ligament space,teeth were catogorized as having widening of the periodontal ligament

Apical periodontitis

If the periapical radiolucency in connection with the apical part of the toothexceeding at least two times the width of the lateral part of the periodontalligament, such teeth were categorized as having obvious periapicalradiolucency

Condition of coronal restoration

Adequate Any permanent restoration that appeared intact radiographically

PoorAny permanent restoration with detectable radiographic signs of overhangs,open margins, or recurrent caries, or presence of temporary coronalrestorations

Missing No permanent or temporary coronal restoration

2. Subjects and Methods

2.1. Patient Selection. This study was undertaken by evaluat-ing the periapical status of teeth on periapical radiographs ofrandomly selected new patients seeking routine dental carebetween the ages of 9 and 71 (median 35) who first pre-sented to the Oral Diagnosis and Radiology Department fora general dental checkup and then were referred to theEndodontics Department of the Faculty of Dentistry, ErciyesUniversity, Kayseri, Turkey. Patients attending to the univer-sity clinic for the first time were selected, and to be includedin the study the patient’s chart had to contain periapicalradiographs made at the Oral Diagnosis and RadiologyDepartment of the school and depicting previous root canaltreated teeth performed by outside dentists. Also, the othercriteria for inclusion in the study were that the patient’schart had to contain periapical radiographs of the previouslyroot canal treated teeth during patient examination. Sincethese periapical radiographs had originally been taken fordefinite radiological diagnosis previously, it was therefore notnecessary to seek ethical approval for this study.

For the study, 1448 roots of 831 endodontically treatedteeth obtained from 484 patients (335 female and 149 male)were evaluated.

2.2. Radiographic Examination. All periapical radiographswere taken with a Trophy CCX X-ray unit (Trophy

Radiographie-94300, Vincenners, France) using Ultra Speedfilm (Eastman Kodak, Roche Sister, NY, USA) and processedwith an automatic film processor according to the man-ufacturer’s instructions. The periapical radiographs wereevaluated by an experienced radiologist using an illuminatedviewer box with ×2 magnification.

2.3. Radiographic Evaluation. The radiographs were analyzedfor several variables such as radiographic quality and healthof the apical status according to the criteria proposed by DeMoor et al. [11] (Table 1).

The criteria proposed by Siqueira et al. [17] were used inthe evaluation of the coronal restorations (Table 1).

Besides the parameters above, if complications such aslateral or furcal perforations and fractured instruments weredetected, the root filling was considered as inadequate.

2.4. Statistical Analysis. Evaluations of the teeth and theroots were analyzed using SPSS software, Version 16.0 (SPSSInc., Chicago, IL, USA). The influence of the endodontictreatments, coronal restorations, existing complications,including other possible combinations on the periapicalhealth were analyzed using the chi-square test. 𝑃 < 0.05values were considered as statistically significant.

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Table 2: Periapical status and related criteria.

Periapical statusTotal Apical periodontitis Healthy Chi-square

𝑛 % 𝑛 % 𝑛 % P valuesGender

Female 259 31,2% 201 77,6% 58 22,4% 0.065Male 572 68,8% 409 71,5% 163 28,5%

Dental archeMaxilla 487 58,6% 371 76,2% 116 23,8% 0.031Mandibula 344 41,4% 239 69,5% 105 30,5%

Tooth typeIncisors 136 16,4% 102 75,0% 34 25,0%

0.002Canines 70 8,4% 46 65,7% 24 34,3%Premolars 282 33,9% 189 67,0% 93 33,0%Molars 343 41,3% 273 79,6% 70 20,4%

Filling lengthPoor 613 73,8% 500 81,6% 113 18,4%

<0.001Adequate 218 26,2% 110 50,5% 108 49,5%

TaperPoor 572 68,8% 456 79,7% 116 20,3%

<0.001Adequate 259 31,2% 154 59,5% 105 40,5%

Filling densityPoor 481 57,9% 401 83,4% 80 16,6%

<0.001Adequate 350 42,1% 209 59,7% 141 40,3%

Type and quality of coronal structureInadequate filling 234 28,2% 189 80,8% 45 19,2%

<0.001Adequate filling 311 37,4% 210 67,5% 101 32,5%Crowned 286 34,4% 211 73,8% 75 26,2%

3. Results

In the study, 1448 roots of 831 teeth obtained from 484patients (with a median age of 35 years) were evaluated. Theroot-filled teeth belonging to females comprised 68.8% of thestudy group whereas those of the males comprised 31.2%.

The types of teeth examined in this study are shownin Table 2. Four hundred eighty-seven were maxillary teeth(58.6%) and 344 were mandibular teeth (41.4%). Of 831 root-filled teeth,molarswere themost frequently treated teeth (𝑛 =343), followed by premolars (𝑛 = 282), incisors (𝑛 = 136),and canines (𝑛 = 70).

The periapical status of all root-treated teeth is presentedin Table 2. Of the 831 root-filled teeth investigated in thestudy, only 26.6% of teeth had healthy periapical structure.The relationship between the periapical status and the genderwas not statistically significant (𝑃 > 0.05); the distribution ispresented in Table 2.

The relationship between the periodontal health and dis-tribution of teeth in dental arches is shown in Table 2,showing that 371 maxillary and 239 mandibular teeth hadapical periodontitis, while the apical periodontiumof only 116maxillary and 105 mandibular teeth was healthy.

Of 831 root-treated teeth, 613 teeth (73.8%) had inade-quate length of filling, being short of the radiographic apex oroverfilled, whereas only 218 (26.2%) had ideal filling length.

The relationship between the periapical health status and thelength of fillings is shown in Table 2.

As another evaluation criteria of root fillings, the smooth-ness and continuity of the taper were examined and only259 teeth (31.2%) were recorded as having ideal taper while572 teeth (68.8%) had inadequate taper (Table 2). There wasa statistically significant relationship between the taper andperiapical health in our study sample (𝑃 < 0.001).

In addition, 57.9% (481) of all root-treated teeth hadinadequate density of filling, while 42.1% (350) had adequatedensity.

A root canal filling was considered adequate only whenthe length, tapering, and density of the fillingwere acceptable.Taking these criteria together, adequate root canal fillingswere found in only 12.8% of all examined samples.

Overall, when the coronal structure of the teeth with rootfillings was evaluated, 34.4% of all had crown restoration.While 28.2% of all root canal-treated teeth had poor ormissing intracoronal restorations, only 37.4% were recordedwith adequate intracoronal restorations (Table 2).

In the present study, without considering the technicalquality of root canal treatments, there is a statistically sig-nificant difference between the prevalence of apical healthof the teeth with poor (19%) and adequate (32%) coronalrestorations (𝑃 < 0.001).


Finally, whenwe looked for the existing complications, 49teeth had been overfilledwith gutta-percha or sealermaterial,30 teeth had broken instruments inside the canals, and 16teeth had apical transportation.

4. Discussion

The population investigated in this study consisted of adultpatients attending the Dental School of Erciyes University,Kayseri, Turkey, for the first time for a periodic checkup orrequired general dental treatment. For the investigation, wearranged a cross-sectional study in order to reveal the situa-tion of endodontic treatments, the quality of the performedtreatments, and the periapical status of the study population,as applied by general dental practitioners.

As a routine examination and diagnosis protocol, we takepanoramic radiographs from most of our patients for adetailed evaluation since all teeth can be seen on oneradiograph and deliver a relatively low patient radiation dosewhen compared with full-mouth sets of periapical radio-graphs. Although panoramic radiographs are accepted to besensitive in the diagnosis of periapical pathosis [18], theaccuracy of panoramic radiographs in the detection of apicalperiodontitis has been questioned [19]. Additionally, becauseof nonuniform magnification and poor imaging of anteriorteeth, we did not find panoramic radiographs sufficient andtook periapical radiographs of the suspected teeth with theapproval of the patients after explaining the necessity, soperiapical radiographs were used instead of panoramic radio-graphs [20]. Also, greater interobserver variability withpanoramic radiographs [2] is another reason for our choiceof periapical radiographs.

A main disadvantage of this cross-sectional study is thatthe radiographs were examined at a given point in time, andno information was available as to the time passed sinceendodontic treatment, so it is impossible to determinewhether a periapical lesion is healing or not [21]. Because aradiograph provides only static information of a dynamicprocess, it is difficult to guess if a periapical lesion is increas-ing or decreasing in size [22]. In order to overcome thesekinds of disadvantages of the present study, patients wereasked to provide the time endodontic treatments or restora-tions were performed, the clinician who performed the work,and the clinician’s level of training, and the time passedbetween the treatment and the observation. According tothe answers, the patients who could not know for certainabout the questions, or whose treatment was not performedby a general dental practitioner, or who had had root canaltreatment within 2 years were excluded from the study.

In the literature, many epidemiological studies haveshown that, because of the poor technical quality of rootfillings, there is a high prevalence of periapical disease in theseteeth. In these studies, there is a wide range of percentage ofinadequate root fillings reported, between 49% and 87%,many of which were undertaken in general practice or hos-pital settings [23]. For several years, most studies reported inthe literature have shown that the technical quality of rootcanal fillings performed by general dental practitioners isoften less than ideal [10, 11, 24, 25]. One of the numerous

possible reasons for this may be the withdrawal of dentalpractitioners from many of the principles and techniquesof endodontics that were covered at dental schools [26, 27]and/or the reported adaptation of many newer techniquesthat have little scientific basis [27]. A study performed in thenortheast of England reported that general dental practi-tioners felt they needed more continuing education andpostgraduate courses to improve their clinical skills inendodontics [28]. On the contrary, results of the studiescarried out in controlled environments have shown that, withhigher technical standards of fillings, the presence of diseaseappears to have a minimal influence on the outcome of thetreatment. Besides, the survival rate of teeth treated byendodontists was shown to be significantly better than thosetreated by general practitioners [29]. In their study, Ingle et al.demonstrated that highly skilled operators are less likely toperform procedural errors that may ultimately compromisethe prognosis [30].

Our study group consisted of 69.2% females and 30.8%males (𝑃 < 0.001). In some epidemiological studies, genderwas reported to have no effect on the number of rootsfilled or the presence of apical periodontitis [15, 31, 32]. Ourresults related to the female prominence were similar to thosereported by Georgopoulou et al. [33] and Sunay et al. [19],which may indicate the greater interest of female patents indental care and attendance for checkups [19].

Maxillary andmandibular molars, followed by premolarswere mostly treated with root canal treatment in our studysample. Compared with mandibulars, maxillary teeth had ahigher prevalence of apical periodontitis. Because maxillarymolars may exhibit many morphological variations of theircomplex root canal anatomies, this may be the reason for thehigher prevalence of failure performed in these teeth [34]. Inaddition, because of the complex anatomy of the maxillaryand zygomatic bones, the difficulty of radiographing themaxillary teeth during treatment and generally the poorerradiographic quality may be the other reasons of the failureof these treatments.

In the present study, 73.4% of the root-filled teeth wereassociated with periapical lesions and only 26.6% of teeth hadhealthy periapical structure. This high percentage was cer-tainly a result of the high frequency of inadequate endodontictreatment in the investigated group, as it is generally acceptedthat the quality of the endodontic treatment strongly influ-ences the status of the periradicular tissues [4, 11, 12, 15].

In our study, a radiographic ruler as a measuring tool wasused to allow an accurate measurement of the proximity ofthe root canal filling relative to the radiographic apex. Thepercentage of root fillings with adequate length was 26.20%in the present study. In the literature, many studies haveconsidered the ideal length of filling within 2mm of theradiographic apex as the gold standard [10, 35, 36], and inSjogren et al. [4] in their highly controlled long-termoutcomestudy, the investigators reported the close relation of healingof apical periodontitis (94%) and the roots filled ideally close(0–2mm) to apex [23]. In the same study, the healing rates ofapical periodontitis of short filled teeth were 68%, while therate was 76% with the overfilled teeth.


As another evaluation criterion of root fillings, the preva-lence of the smoothness and continuity of the taper in thepresent study was 31.2% while the remainder had 68.8% ofinadequate taper. Because the taper of root canals is a moresubjective criterion, in the literature only a few reportshave been published on this matter [37]. In a recent studyperformed by Bierenkrant et al. [23], the authors reported themajority of the canals had a “smooth and continuous” taper of83.8% prevalence rate [23].The same authors correlated theirhigh rate with the benefit of rotaryNiTi instrumentation [23].As the European Society of Endodontology (1994) advises thepreparation of root canals should be tapered from crown toapex, we believe in the future, with the use of NiTi rotaryinstruments, the philosophies of both instrumentation andfilling of the root canals will be changed in a positive manner.Additionally, we found a statistically significant relationshipbetween the taper and periapical health in our study sample(𝑃 < 0.001).

In the literature, there is conflicting evidence related tothe impact of root-filling density on prognosis [23]. Somestudies have shown that teeth with homogenous root fillingswill result in more consistent healing [7] and survival [38],whereas some of the other studies reported no difference inthe prognosis of root canal treatment [4], and some reporteda significantly increasing prevalence of apical periodontitiswith nonhomogenous and inadequately compacted rootfillings [16, 39, 40]. In the present study, 57.9% (481) of all root-treated teeth had inadequate density of filling, while 42.1%(350) had adequate filling density.

A root canal filling was considered adequate only whenthe length, tapering, and density of the fillingwere acceptable.With these criteria together, adequate root canal fillings werefound in only 12.8% of all examined samples. Unfortunately,this prevalence result is the lowest of all reviewed articlespublished in the literature, among which was reported anacceptable root filling in the range of 17.7–64.5% [23, 41].When considering the treatment adequacy between the toothtypes, there was no statistically significant difference in ourstudy sample (𝑃 > 0.05).

The quality of the coronal seal is another important factorthat influences the periapical health [41]. Inmany studies, theassociation between the quality of the coronal seal and thepresence of periapical radiolucencies were shown in a neg-ative correlation [21, 41–43]. In the present study, when thecoronal structure of the root canal-treated teeth was evalu-ated, 34.4% of all had crown restoration. While 28.2% of allroot canal-treated teeth had poor or missing intracoronalrestorations, only 37.4% were recorded with adequate intra-coronal restorations (Table 2).

In the present study, teeth without or inadequate coronalrestoration had significantly more periapical pathology com-pared to those with adequate coronal restorations (Table 2).Without considering the technical quality of root canal treat-ments, there is a statistically significant difference betweenthe prevalence of apical health of the teeth with poor (19%)and adequate (32%) coronal restorations (𝑃 < 0.001).

Ingle et al. [30] demonstrated in their study that highlyskilled operators are less likely to perform procedural errorsthat may ultimately compromise the prognosis. For the

present study, 49 teeth had overfilled gutta-percha or sealermaterial, 30 teeth had broken instruments inside the canals,and 16 teeth had apical transportation. It is clear that theoperator skill and the condition under which the treatmentwas delivered are important factors that should not be under-estimated on the prognosis of the treatments [18].

5. Conclusion

Within the limitations of this study, the technical qualityof root filling performed by dental practitioners in Kayseri,Turkey, is very low compared to other studies. The prob-able reasons for this failure are multifactorial and may beimproved if the operators improve their skills with continuingpostgraduate education programs.

Conflict of Interests

The authors declare that there is no conflict of interests.

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